AVIATION SAFETY

FAA Should Improve 

Usability of its Online 

Application System 

and Clarity of the 

Pilot's Medical Form 

Report to Congressional Committees

April 2014

GAO-14-330

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-330, a report to

congressional committees

April 2014

AVIATION SAFETY

FAA Should Improve Usability of its Online 

Application System and Clarity of the Pilot’s Medical 

Form

Why GAO Did This Study

FAA developed its medical standards 

and pilot’s medical-certification process 

to identify pilot applicants with medical 

conditions that may pose a risk to flight 

safety. The Pilot’s Bill of Rights (P.L.

112-153) mandated GAO to assess 

FAA’s medical certification standards, 

process, and forms.

This report addresses: (1) FAA’s 

medical standards, policies, and 

certification processes, along with 

medical experts’ views on them, and 

(2) steps that FAA could take to 

promote private pilots’ understanding 

of its medical requirements. GAO 

reviewed statutes, regulations, FAA 

documents, and interviewed officials 

from FAA, NTSB, pilot associations, 

and 20 aviation medical experts 

primarily identified by the National 

Academies’ Institute of Medicine. 

Experts were selected based on their 

type and depth of experience, including 

recognition in the aerospace-medicine 

professional community. GAO also 

interviewed FAA’s medical certification

division and evaluated the usability of 

FAA’s online application system and 

the clarity of its application form 

against federal writing guidelines and 

best practices in website usability.

What GAO Recommends

GAO recommends that FAA (1) 

develop a timeline for implementing 

high-priority technological 

improvements to the internal computer 

systems that support the medical 

certification process, and (2) enhance 

the online medical-application system 

by clarifying instructions and questions 

on the form and providing useful 

information. The Department of 

Transportation agreed to consider the 

recommendations.

What GAO Found

Aerospace medical experts GAO interviewed generally agreed that the Federal 

Aviation Administration’s (FAA) medical standards are appropriate and supported 

FAA’s recent data-driven efforts to improve its pilot medical-certification process. 

Each year, about 400,000 candidates apply for a pilot’s medical certificate and 

complete a medical exam to determine whether they meet FAA’s medical 

standards. From 2008 through 2012, on average, about 90 percent of applicants

have been medically certified by an FAA-designated aviation medical examiner

(AME) at the time of their medical exam or by a Regional Flight Surgeon. Of the 

remaining applicants, about 8.5 percent have received a special issuance 

medical certificate (special issuance) after providing additional medical 

information to FAA. Approximately 1.2 percent were not medically certified to fly. 

According to an industry association, the special issuance process adds time and 

costs to the application process, in part, because applicants might not 

understand what additional medical information they need to provide to FAA. 

Officials from FAA’s medical certification division have said that technological 

problems with the aging computer systems that support the medical certification 

process have contributed to delays in the special issuance process. FAA’s 

medical certification division has identified about 50 potential technological 

enhancements to its internal computer systems that support the medical 

certification process, of which about 20 have been identified as high priority, but 

the division has not yet implemented them or developed a timeline to do so. By 

developing a timeline to implement the highest-priority enhancements, FAA 

would take another step toward expediting the certification process for many 

applicants hoping to obtain a special issuance. FAA recently established a datadriven process using historic medical and accident data that authorizes AMEs to 

certify a greater number of applicants with medical conditions who had previously 

required a special issuance. Officials expect this effort to allow more applicants to 

be certified at the time of their AME visit and to free resources at FAA to focus on 

applicants with higher-risk medical conditions.

GAO’s analysis and medical experts’ opinions indicate that FAA could improve its 

communication with applicants by making its online application system—part of 

FAA’s internal computer systems discussed above—more user-friendly and 

improving the clarity of the medical application form. Specifically, GAO found that

the online application system requires applicants to scroll through a lengthy 

terms-of-service agreement and does not provide clear instructions, and that the 

application form contained unclear questions and terms that could be 

misinterpreted by the applicant. FAA could enhance its online application system

by using links to improve navigability of the system and providing information that 

is more useful to applicants—for example, links to information about the risk that 

specific medical conditions pose to flight safety and any additional medical 

information applicants with those conditions would need to provide to FAA. FAA 

could also improve the clarity of its medical application form by incorporating 

guidelines established in FAA’s Writing Standards, including shorter sentences 

and paragraphs, active voice, and clear terms and questions. These clarifications 

could not only aid an applicant’s understanding of the medical standards and 

requirements, but also may result in more accurate and complete information 

provided by applicants to better inform FAA’s certification decisions.

View GAO-14-330. For more information, 

contact Gerald L. Dillingham, Ph.D., at (202) 

512-2834 or dillinghamg@gao.gov.
Page i GAO-14-330 Aviation Safety

Letter 1

Background 4

Experts Generally Agreed with FAA’s Medical Standards and 

Supported FAA’s Move toward a Data-Driven Approach to Its 

Certification Process 8

FAA Could Enhance its Online Application System and the Clarity 

of its Medical Application Form for Private Pilots 20

Conclusions 29

Recommendations for Executive Action 30

Agency Comments 30

Appendix I Objectives, Scope, and Methodology 31

Appendix II Summary of Selected FAA Medical Standards 36

Appendix III Selected FAA Training Programs for AMEs and Pilots in 

Aerospace Medicine and Communication Tools 37

Appendix IV FAA Form 8500-8 (Medical Application Form) 39

Appendix V GAO Contact and Staff Acknowledgments 42

Tables

Table 1: Frequency of Medical Certification Requirement and 

Distribution of Pilots by Medical Class (2011) 5

Table 2: List of Medical Experts 33

Figures

Figure 1: Overview of FAA’s Medical Certification Process 7

Figure 2: Screenshot Showing Small Window through which the 

Reader Must Scroll Pages of Information 24

Contents
Page ii GAO-14-330 Aviation Safety

Abbreviations

AASI AME Assisted Special Issuance (see below for AME)

ALPA Air Line Pilots Association

AMCD Aerospace Medical Certification Division 

AME Aviation Medical Examiner 

AMSIS Aerospace Medicine Safety Information System 

AOPA Aircraft Owners and Pilots Association 

CACI Conditions an AME Can Issue

CAMI Civil Aerospace Medical Institute 

DIWS Document Imaging Workflow System 

FAA Federal Aviation Administration 

FDA Food and Drug Administration 

EAA Experimental Aircraft Association 

ECG electrocardiogram 

ITDM insulin-treated diabetes mellitus 

MOU memorandum of understanding 

NTSB National Transportation Safety Board 

OMB Office of Management and Budget

SMS Safety Management System 

SODA Statement of Demonstrated Ability 

SSRI selective serotonin reuptake inhibitors

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

copyrighted images or other material, permission from the copyright holder may be 

necessary if you wish to reproduce this material separately.
Page 1 GAO-14-330 Aviation Safety

441 G St. N.W.

Washington, DC 20548

April 8, 2014

The Honorable John D. Rockefeller IV

Chairman

The Honorable John Thune

Ranking Member

Committee on Commerce, Science, and Transportation

United States Senate

The Honorable Bill Shuster

Chairman

The Honorable Nick J. Rahall II

Ranking Member

Committee on Transportation and Infrastructure

House of Representatives

The primary mission of the Federal Aviation Administration (FAA) is to 

ensure a safe and efficient flying environment. As part of its mission, FAA 

oversees the medical certification of about 600,000 pilots1 to certify that 

they meet FAA’s medical standards and are physically and mentally fit to 

fly. According to FAA officials, most applicants for a medical certificate 

meet FAA’s medical standards and are medically certified after 

completing a physical exam by a FAA-designated physician. However, for 

applicants with a disqualifying medical condition, FAA’s Federal Air 

Surgeon may, on a case-by-case basis, authorize a special issuance 

medical certificate (special issuance) for a specified period. An 

authorization for a special issuance requires the applicant to show to the 

satisfaction of the Federal Air Surgeon that the required operations can 

be performed without endangering public safety during the period of the 

special issuance. Medical conditions that generally disqualify applicants 

from medical certification to fly include certain heart conditions, diabetes, 

epilepsy, impaired hearing or vision, psychosis, drug and alcohol 

dependence, and also generally any disease, defect, or treatment that 

could prevent a pilot from safely operating an aircraft.2

 1

Persons not required to hold a medical certificate include, among others, sport pilots, with 

glider and balloon privileges (14 C.F.R. § 61.23(b)). 

About 10 percent 

2

Specific medical standards and certification procedures for issuing medical certificates 

and for remaining eligible for a medical certificate are set out in federal regulations at 14 

C.F.R. Part 67.
Page 2 GAO-14-330 Aviation Safety

of applications—nearly 40,000 a year—may require, among other things, 

further medical evaluation, medical flight testing, or submitting additional 

documentation that can add time to the certification process. However, 

through the special issuance process, FAA has allowed some pilots to fly 

for a specified period with heart transplants, permanent cardiac 

pacemakers, and insulin-treated diabetes mellitus, among other 

conditions that would otherwise disqualify pilots from flying.

The Pilot’s Bill of Rights mandates that GAO assess FAA’s medical 

certification process and the associated medical standards and forms.3

• FAA’s medical standards and certification processes, along with 

medical experts’ views on them, and

This report discusses

• steps that could be taken to promote private pilot applicants’ 

understanding of FAA’s medical requirements, including potential 

revisions to the medical application form.4

To address our objectives, we commissioned the Institute of Medicine of 

the National Academies to identify experts knowledgeable about aviation 

medicine.5

 3

Pub. L. No. 112-153, 126 Stat. 1159 (2012).

From the list of 24 experts identified by the National 

Academies, seven experts were either unavailable, had concerns over 

their ability to respond to the questions because of their unfamiliarity with 

4

Federal regulations establish three classes of medical certification that correspond to the 

duties that pilots perform. First- and second-class pilots fly for commercial purposes, 

whereas third-class pilots fly for noncommercial (private) purposes. The pilot medical 

certification process is similar for all classes of pilots. The General Aviation Pilot 

Protection Act of 2013 (H.R. 3708, 113th Cong. (2013)) was introduced in December 2013 

and, if enacted into law, would eliminate the medical certification requirement, under a 

specific set of conditions, for private (third-class) pilots flying recreationally. We did not 

review the proposed legislation and its potential implications as part of this study.

5

We selected these experts based on their relevant experience in aviation medicine. The 

experts represented private, public, and academic institutions. Fourteen of the experts are 

board certified by at least one of the American Board of Medical Specialties member 

boards, including nine who are board certified in aerospace medicine. Eight of the 20 

medical experts we interviewed are Aviation Medical Examiners (AMEs) for the FAA, and 

16 are pilots or have had pilot experience in the past. Two experts are from aviation 

authorities in Australia and New Zealand, and a third expert was from the United Kingdom. 

We asked each interviewee to verify that they had no conflicts of interest in participating in 

our study.
Page 3 GAO-14-330 Aviation Safety

FAA’s medical certification program, or had a conflict of interest, and we 

added three experts recommended to us, for a total of 20 aviation medical 

experts. We conducted semi-structured interviews of the experts to solicit 

their views on FAA’s medical standards, the medical application form, and 

FAA’s communication with physicians and pilot applicants. We also 

interviewed officials from FAA, and we visited the Civil Aerospace Medical 

Institute (CAMI) in Oklahoma City to interview representatives of FAA’s 

Aerospace Medical Certification Division (AMCD) about FAA’s medical 

standards, the medical application form, and FAA’s methods for 

communicating pilot medical-certification information with physicians and 

pilot applicants. In addition, we interviewed officials from the National 

Transportation Safety Board (NTSB), representatives from two pilot 

associations, and representatives from the American Diabetes 

Association.6 We also received written responses from three regional 

airline representatives and two aviation medical associations regarding 

their views on FAA’s current medical standards, the clarity of the medical 

form, and FAA’s efforts to provide information to pilots and pilot 

applicants.7

We conducted this performance audit from January 2013 through April 

2014, in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

Further, we analyzed FAA’s Form 8500-8 (medical 

application form) and MedXPress.faa.gov (FAA’s online application 

system), against the federal government’s plain language and website 

usability guidelines. (See app. I for further information on our scope and 

methodology, including a list of medical experts we interviewed.)

 6

We also contacted the American College of Cardiology and the American Academy of 

Neurology to solicit their views, but they did not reply for an interview.

7

Throughout the remainder of the report, we use the term “applicant” to refer to new 

applicants and to pilots who are applying to periodically renew their medical certificate.
Page 4 GAO-14-330 Aviation Safety

According to FAA officials, FAA’s medical certification requirement was 

established to prevent or mitigate the effect of various medical conditions 

that present an undue risk to the safety of pilots, passengers, or others.8

While most general aviation accidents are attributed to pilot error 

involving a loss of aircraft control, according to information provided by 

NTSB,9 medical causes were a factor in approximately 2.5 percent of the 

accidents from 2008 through 2012.10 By ensuring that applicants meet 

medical standards, FAA aims to reduce the likelihood of incapacitation of 

a pilot due to a medical cause.11

Federal regulations establish three classes of medical certification that 

correspond to the types of operations that pilots perform. Airline transport 

pilots who serve as pilots in command of scheduled air-carrier operations 

must hold first-class medical certificates. Pilots who fly for compensation 

or hire generally hold second-class medical certificates. Private pilots hold 

 8

Among other statutory authorities, the Administrator of the FAA is required to promote 

safe flight of civil aircraft (49 U.S.C. § 44701) is authorized to issue airman certificates (49 

U.S.C. § 44702) and is required to issue such certificates after investigation that the 

individual is qualified for, and physically able to perform the duties of the position 

authorized by the certificate (49 U.S.C. § 44703).

9

The National Transportation Safety Board is an independent federal agency charged by 

Congress with investigating every civil aviation accident in the United States and 

significant accidents in other modes of transportation. The NTSB determines the probable 

cause of the accidents and issues safety recommendations aimed at preventing future 

accidents.

10Under 49 C.F.R. § 830.2, an aircraft accident means an occurrence associated with the 

operation of an aircraft that takes place between the time any person boards the aircraft 

with the intention of flight and all such persons have disembarked, and in which any 

person suffers death or serious injury, or in which the aircraft receives substantial 

damage. NTSB officials told us that the actual portion of accidents with medical causes or 

contributing factors may be higher because they do not investigate all accidents in the 

same way, making it difficult to identify medical causes in some cases. According to NTSB 

officials, methods of accident investigation may vary, depending on whether or not the 

accident was fatal, the condition of the aircraft and pilot, and other factors. Additionally, 

according to FAA officials, 30 to 50 percent of fatal accidents are attributed to faulty 

aeronautical decision making. FAA officials also said that human behavior is recognized 

as a key component of aeronautical decision making, but the specifics of medical 

contributing factors—for example, the role of fatigue secondary to obstructive sleep 

apnea—are not well mapped. 

11We use the term incapacitation to refer to sudden or subtle forms of incapacitation. Any 

medical certification process would be unlikely to prevent all accidents with medical 

causes due to the unpredictable nature of some medically incapacitating events, such as 

a heart attack, and the relative infrequency of the medical evaluations for some pilots.

Background
Page 5 GAO-14-330 Aviation Safety

third-class medical certificates. (See table 1.) Depending on their age and 

the class of medical certificate sought, pilots must renew their medical 

certificate periodically, from every 6 months to every 5 years (e.g., 

commercial pilots—generally those needing first- or second-class medical 

certificate—must have their medical certificate updated more frequently 

than private pilots). After obtaining a medical certificate, and between 

renewal periods, pilots are prohibited from performing pilot operations 

when they know or have reason to know of a medical deficiency that 

would make them unable to fulfill their pilot operation.12

Table 1: Frequency of Medical Certification Requirement and Distribution of Pilots by Medical Class (2011)

Class of certificate Age Frequency

Approximate percentage of 

pilots per class

First class (commercial) > 40 years of age Every 6 months 8.4

< 40 years of age Every year 12.4

Second class (commercial) > 40 years of age Every year 3.3

< 40 years of age Every year 11.8

Third class (private) > 40 years of age Every 2 years 30.8

< 40 years of age Every 5 years 33.4

Source: GAO analysis of FAA data from 2011 Aerospace Medical Certification Statistical Handbook.

In the fiscal year 2014 budget submission, FAA estimated that its Office 

of Aerospace Medicine would need about $56.1 million in funding—about 

4.7 percent of the total Aviation Safety budget—to carry out its mission. 

To assist in the nearly 400,000 medical evaluations of pilots and new 

applicants13

 12Pursuant to 14 C.F.R. § 61.53(a), Prohibition on operations during medical deficiency

prohibits a person who holds a medical certificate from acting as pilot in command or in 

any other capacity as a required pilot flight crew member while that person: (1) “knows or 

has reason to know of any medical condition that would make the person unable to meet 

the requirements for the medical certificate necessary for the pilot operation”; or, (2) “Is 

taking medication or receiving other treatment for a medical condition that results in the 

person being unable to meet the requirements for the medical certificate necessary for the 

pilot operation.”

each year, FAA designates medical certification authority to 

approximately 3,300 private physicians, or Aviation Medical Examiners 

(AMEs). The AMEs review applicants’ medical histories and perform 

physical examinations to ensure that applicants meet FAA’s medical 

13Throughout the remainder of the report, we use the term “applicant” to refer to new 

applicants and to pilots who are applying to periodically renew their medical certificate.
Page 6 GAO-14-330 Aviation Safety

standards and are medically fit to operate an aircraft at the time of their 

medical exam. Although AMEs are not FAA employees, they are trained 

in aviation medicine by the FAA and entrusted to make medical eligibility 

determinations for the majority of applicants, on behalf of the FAA. In 

order to become an AME and be authorized to administer medical exams, 

FAA requires AMEs to complete online courses in clinical aerospace 

physiology and medical certification standards and procedures before 

attending a one-week basic AME seminar. AMEs must also complete at 

least 10 pilot medical exams each year and a subsequent refresher 

courses every 3 years.14

All applicants for medical certificates and renewals follow a similar 

process. Applicants begin the medical certification process by completing 

Form 8500-8, Application for Airman Medical Certificate or Airman 

Medical & Student Pilot Certificate (medical application form) in 

MedXPress (online application system). For applicants with disqualifying 

medical conditions or for those who do not meet FAA’s medical 

standards, the AME must defer the applicant to FAA to authorize a 

special issuance. The special issuance process may require additional 

medical information and evaluations from, for example, a primary care 

physician or medical specialist. Also, a special issuance may be subject 

to operational limitations for safety reasons, or may be valid for a shorter 

time period than an unrestricted medical certificate. As a provision of the 

special issuance, FAA may authorize AMEs to make future medical 

determinations of the applicant—separate from the centralized special 

issuance process—under the AME Assisted Special Issuance (AASI) 

process.15

 14FAA annually issues an Individual AME Performance Summary Report to each AME, 

which summarizes AME training and performance to help ensure that the AME completes 

required training and submits medical exam results to FAA in a timely manner. FAA has 

also developed a quality assurance review program to help it determine that AMEs have 

properly issued medical certificates. See GAO, Aviation Safety: FAA Has Taken Steps to 

Determine That It Has Made Correct Medical Certification Decisions, 

Figure 1 describes the medical certification process and 

various outcomes.

GAO-08-997

(Washington, D.C.: Sept. 17, 2008).

15Alternatively, if FAA determines that an applicant’s medical condition is static and nonprogressive and has found the applicant capable of performing pilot duties without 

endangering public safety, the FAA may grant a Statement of Demonstrated Ability 

(SODA) to the applicant, which does not expire and authorizes AMEs to make future 

medical determinations of the applicant, without requiring the applicant to go through the 

special issuance review process.
Page 7 GAO-14-330 Aviation Safety

Figure 1: Overview of FAA’s Medical Certification Process

According to FAA, on average, from 2008 through 2012, approximately 

98.8 percent of the applications were approved and issued medical 

certificates, including approximately 8.5 percent of applications approved 

for a special issuance after additional FAA review. About 1.2 percent of all 

applications were denied an FAA medical certificate because (1) they did 

not meet FAA’s medical standards and did not provide sufficient medical 
Page 8 GAO-14-330 Aviation Safety

information to demonstrate that their condition was adequately controlled 

and stable, or (2) because of questions about the applicant’s fitness for 

certification that were deemed to be cause for disqualification, such as 

arrest(s) and/ or conviction(s) affecting driving privileges or an intentional 

false statement on their application form that precluded them from 

obtaining a medical certificate.16 FAA regulations require each person 

holding certain FAA certificates, such as a medical certificate, to provide a 

written report to the FAA of each motor-vehicle-related conviction or 

administrative action within 60 days of such action.17

According to FAA officials, pilot medical standards were developed to 

help manage safety risk. FAA’s current medical standards have been 

codified in federal regulation since March 19, 1996. The regulations set 

out 15 medical conditions that are specifically disqualifying. Medical 

conditions identified during an evaluation that are not specifically listed as 

disqualifying but do not meet the general medical standard regarding safe 

 16Applicants who are denied medical certification by an AME or the FAA may appeal the 

decision (14 C.F.R. § 67.409, 49 U.S.C. 44703(d)); however, according to FAA officials 

most applicants who are denied medical certification do not pursue an appeal or do not 

provide FAA with additional requested information necessary for a special issuance. A 

denial is considered a “final” action by the FAA and is subject to review by the NTSB. The 

Manager of AMCD and Regional Flight Surgeons may also issue a final denial to an 

applicant who fails to provide additional requested information within the time frame 

specified by FAA. Based on information provided by FAA, from 2008 through 2012, on 

average, approximately 4,930 applicants were denied each year, and about 12 percent of 

those denials were deemed final by FAA. 

1714 C.F.R. § 61.15(e).

Experts Generally 

Agreed with FAA’s 

Medical Standards 

and Supported FAA’s 

Move toward a DataDriven Approach to 

Its Certification 

Process

FAA Uses Several 

Approaches to Update Its 

Medical Standards
Page 9 GAO-14-330 Aviation Safety

performance of duties and exercise of privileges, are also disqualifying 

under general medical standards, according to FAA. (See app. II for a 

summary of selected FAA medical standards.) According to FAA officials, 

the standards and the medical certification process were developed to 

manage the risk of an aircraft accident or incident by identifying 

applicants with medical conditions that could potentially incapacitate them 

in the flight environment or during critical take-off and landing periods.18

FAA takes steps designed to ensure that its medical policies and 

procedures are consistent with current medical and aeromedical practice, 

and that these steps result in periodic updates to its medical policies. The 

Federal Air Surgeon establishes medical policies and medical certification 

procedures that are published in internal guidance for FAA’s Office of 

Aerospace Medicine and for AMEs in the Guide for Aviation Medical 

Examiners (AME Guide). The agency uses several techniques to update 

policies:

• First, the Aeromedical Standards and Policies Branch develops policy 

recommendations for the Federal Air Surgeon, which address medical 

conditions, medication use, and medical procedures. According to 

FAA officials, medical policy review is a continuous process 

influenced by several factors, which include (1) announcements of 

significant new developments in the medical literature; (2) medical 

appeals to the Federal Air Surgeon; (3) announcements and alerts by 

the Food and Drug Administration; (4) inquiries by aviation 

stakeholder groups and pilot advocacy groups; (5) aircraft accidents 

or events; (6) inquiries by the Office of Aerospace Medicine personnel 

and AMEs; and (7) communications with international aviation 

authorities, and medical advocacy groups, among other things.

• Second, according to FAA officials, the agency refers dozens of 

individual cases annually for independent review by experts in a wide 

 18Because medical incapacitation risk is a factor of the likelihood an incapacitating medical 

event and the consequence of the event, FAA also may manage medical incapacitation 

risk by building redundancies in the flight environment, for example, as FAA currently 

manages safety risk, by requiring co-pilots for commercial flight. According to FAA 

officials, in addition to 'sudden' incapacitation, several other potential medical causes for 

aircraft accidents are considered in the medical evaluation process. These include: 

factors that could alter judgment, conditions that can alter special senses (such as visual 

acuity and color vision), factors that could alter the ability to communicate, conditions that 

may cause difficulty with coordination or may alter the state of alertness, and medication 

side effects.
 

Page 10 GAO-14-330 Aviation Safety

variety of medical specialties, such as cardiology, psychology, and 

neuropsychology. FAA officials stated that implicit to the process of 

reviewing each case is to consider changes to current policy based on 

current medical practice. FAA also periodically uses independent 

medical experts to evaluate its medical policies, particularly with 

regard to cardiovascular conditions, which were present in more than 

one-third of the applicants who received special issuances in 2012. In 

January 2013, for example, FAA hosted a cardiology roundtable to 

review FAA’s policies with regard to cardiovascular conditions and to 

suggest updates to the policies, if necessary. The roundtable’s 

suggested policy changes were presented to the Federal Air Surgeon, 

who approved several of them. However, FAA officials have said that 

they do not convene such roundtables frequently due to time and cost 

constraints.

• Third, the results of CAMI’s aerospace medical and human factors 

research have been used to inform changes to FAA guidance and 

policies. In particular, CAMI’s aerospace medical research focuses on 

the biomedical aspects of flight, including studies on aviation safety 

associated with biomedical, pharmacological, and toxicological issues. 

For example, CAMI’s research on sedating medication influenced 

guidance in this area. According to FAA officials, a review of accident 

investigation data showed that many pilots involved in accidents were 

using over the counter and prescription sedative medications. As a 

result, FAA, in coordination with the aviation industry, issued guidance 

extending the length of time a pilot should wait after using these 

medications and before operating an aircraft. A letter jointly signed by 

the FAA and all major aviation advocacy groups was sent to all pilots 

and published on the FAA website and in various public and private 

publications advising pilots to comply with the new guidance.

• Fourth, CAMI’s library allows research staff to collect and review 

academic journals on aviation medical issues, general medical 

research, engineering, management, and other general topics. CAMI 

researchers have also published approximately 1200 aerospace 

medicine technical reports on topics including, for example, pilot age, 

alcohol and substance abuse, fatigue, psychology, and vision.19

 

19

FAA’s policy branch periodically reviews this and other medical 

literature, which FAA officials say can also result in a possible 

revision.

http://www.faa.gov/data_research/research/med_humanfacs/oamtechreports/. 
Page 11 GAO-14-330 Aviation Safety

In addition, FAA has recently begun analyzing aviation accident 

information to develop a predictive model based on historic data of 

medical conditions that have been identified as contributing factors to 

aircraft accidents. The officials stated that they plan to use the model as a 

data-driven guide to help inform how they determine the relative risk of 

various medical conditions. FAA officials noted that the agency has begun 

this work as part of a broader Safety Management Systems (SMS) 

initiative that seeks to further enhance safety by shifting to a data-driven, 

risk-based oversight approach.20

All aerospace medical experts we interviewed generally agreed that 

FAA’s medical standards were appropriate, and most (16 of 20) said that 

the standards should be applied to commercial and private pilots.21

Although expert opinions varied regarding which standards were too 

permissive or restrictive, neurological issues were most commonly

Some 

of these experts said that standards should apply equally to private pilots 

because they share airspace with commercial pilots or because private 

pilots typically do not fly with a copilot—an important safety feature for 

commercial flight operations. In addition, although some of the experts (7 

of 20) suggested no changes to FAA’s policies, many of the experts (13 

of 20) identified at least one medical standard for which they considered 

FAA’s policies to be either too restrictive or too permissive. A restrictive 

policy might lead FAA to deny certification to an applicant who may be 

sufficiently healthy to safely fly a plane, or may result in FAA requiring a 

more thorough medical evaluation than the experts considered 

necessary. A permissive policy, on the other hand, might lead FAA to 

certify an applicant with health issues that could impair his or her ability to 

safely fly a plane, or may result in FAA not completing as thorough a 

medical evaluation as the experts considered necessary.

 20See, for example, GAO, Aviation Safety: Additional FAA Efforts Could Enhance Safety 

Risk Management, GAO-12-898 (Washington, D.C.: Sept. 12, 2012).

21We interviewed 20 aviation medical experts and we use the indefinite quantifiers (“few” = 

2-3 experts; “some” = 4-9 experts; “half” = 10 experts; “many” = 11-15 experts; “most” = 

16-19 experts) to inform the reader of the approximate quantity of medical experts who 

agreed with the particular statement or idea (See app. I for an explanation of how these 

indefinite quantifiers are used, and a list of medical experts interviewed.)

Experts Generally Agreed 

FAA’s Medical Standards 

Are Appropriate, but Some 

Experts Suggested 

Modifying Some Policies
Page 12 GAO-14-330 Aviation Safety

discussed by some (9 of 20) of the experts.22

Alternately, some medical experts said that policies regarding cognitive 

functioning in aging pilots, traumatic head or brain injuries, and attention 

deficit disorders may be too permissive. An FAA official stated that the 

area of neurology is complex and has been somewhat difficult for AMCD 

due, in part, to variation in opinion as to how to assess cognitive function 

and when testing should be done. The agency hosted a neurology 

summit in 2010 that convened neurology experts to review FAA policies 

on neurological issues—including traumatic brain injury, migraine 

headaches, and neurocognitive testing—and resulted in 

recommendations that the Federal Air Surgeon adopted regarding 

migraine treatments, among other neurological conditions. Also, the 

Division Manager of AMCD said that they consult with neurologists, as 

needed, to review the application of certification policies regarding 

individual applicant cases.

For example, some experts 

noted that the FAA medical certification requirements for applicants who 

use antidepressants, including selective serotonin reuptake inhibitors 

(SSRI), are restrictive and onerous and may require an applicant not to fly 

for an extended period of time. A medical representative from the Aircraft 

Owners and Pilots Association (AOPA) said that FAA’s policies may 

require a pilot using antidepressants to undergo costly cognitive studies 

that were viewed as medically unnecessary for milder cases of 

depression.

 22We interviewed 20 individuals with broad aerospace medicine expertise to provide their 

expert opinion on FAA’s medical standards and qualification policies. Our criteria for 

identifying and selecting experts included (1) type and depth of experience, including 

recognition in the aerospace medicine professional community and relevance of any 

published work; (2) employment history and professional affiliations, including any 

potential conflicts of interest; and (3) other relevant experts’ recommendations. Our group 

of experts includes AMEs and pilots, as well as experts from aviation authorities in the 

United Kingdom, Australia, and New Zealand. Fifteen of the experts are board certified by 

at least one of the American Board of Medical Specialties’ member boards, including nine 

who are board certified in aerospace medicine. We provided all medical experts with 

relevant background information prior to our interview, and we provided the option to 

bypass questions if experts believed they were unqualified to respond in a professional 

capacity. While the experts provided their opinions on some specific standards, we do not 

believe that these opinions alone provide sufficient evidence to recommend any specific 

changes to FAA medical standards and policies. Rather, the information from these 

interviews provides us with an overall expert assessment of FAA’s medical standards, 

policies, and practices.
Page 13 GAO-14-330 Aviation Safety

To a lesser extent, some (5 of 20) experts had mixed views on the 

policies for diabetes and medical conditions related to endocrine function. 

Of those, three experts thought that FAA’s current policies on diabetes 

might be too restrictive, for example, because the FAA has not kept pace 

with medical advances and treatment options currently available to pilots. 

One expert noted that some commercial pilots with insulin treated 

diabetes mellitus (ITDM) may be medically fit to fly a plane with a special 

issuance if they can demonstrate that their condition is stable, just as 

private pilots are allowed to do. In addition, representatives from the 

American Diabetes Association and a member of the Regional Airline 

Association stated that FAA’s policies for commercial pilots with ITDM 

have not kept current, when considering the advancements in medical 

treatment of ITDM and the redundancy of having a copilot and crew in 

commercial aircraft to reduce the risk associated with commercial pilots 

with ITDM. Conversely, two experts thought that FAA may be too 

permissive with regard to diabetes, citing, for example, concerns about 

the increase in diabetes among Americans, in general, and the potential 

for undiagnosed cases.23

All of the experts suggested ways FAA could ensure its medical 

standards are current, many of which were consistent with approaches 

FAA is already taking. For example, some of the experts (9 of 20) said 

FAA could review its medical standards at regular time intervals or as 

medical advances occur, and some (8 of 20) of the experts said FAA 

could review its medical standards based on evidence of the likelihood of 

each condition causing an accident. Some experts (5 of 20) specifically 

suggested FAA should convene a panel on neurology and mental health 

issues. FAA convened a panel on neurological issues in 2010.

FAA officials agreed that there have been 

improvements in the clinical care for diabetes and the Office of Aerospace 

Medicine has studied the safety and efficacy of new diabetes treatment 

over the past several years, including the risks associated with new 

medications and insulin formulations. However, according to FAA 

officials, independent consultants—including endocrinologists and 

diabetes experts—have told the FAA that the risk of incapacitation related 

to hypoglycemia has not changed regardless of advancements in 

treatment.

 23A few experts (3 of 20) also identified standards related to cardiovascular and drug or 

alcohol use as too permissive or restrictive.
Page 14 GAO-14-330 Aviation Safety

As previously mentioned, FAA is currently undertaking an agency-wide 

initiative—SMS—that seeks to further enhance safety by shifting to a 

data-driven, risk-based safety oversight approach. As part of this 

approach, FAA implemented the Conditions an AME Can Issue, or CACI, 

program in April 2013. The CACI program authorizes AMEs to issue 

medical certificates to applicants with relatively low risk medical 

conditions that had previously required a special issuance from the 

FAA.24

Based on information provided by FAA, as of December, 31, 2011, 

approximately 19 percent of all pilots reported medical conditions that 

may now be evaluated by their AME as a result of the CACI program. Of 

those pilots, about one-third—or nearly 39,000 pilots—reported no 

additional medical conditions, making it more likely that in the future, they 

may be certified at the time of their AME visit, rather than through the 

special issuance process. Other medical conditions have been proposed 

for the CACI program but have not yet been approved by FAA officials.

FAA developed the program by identifying medical conditions that, 

in most cases, did not pose a safety risk, based on FAA analysis of 

historic medical and accident data. Agency officials expect the program to 

allow more applicants to be certified at the time of their AME visit while 

freeing resources at FAA to focus on medically complex applicants with 

multiple conditions or medical conditions that may pose a greater risk to 

flight safety, such as applicants who have had coronary artery bypass 

surgery.

25

Some (8 of 20) aerospace medical experts we interviewed identified 

specific, relatively common medical conditions that currently require an 

Most medical experts (18 of 20) we interviewed approved of the CACI 

program, and some (8 of 20) believed that FAA should continue to 

expand it to include additional medical conditions. Representatives of an 

industry association agreed and noted that by authorizing AMEs to make 

a greater number of medical certification decisions, AMCD officials could 

speed up the application process for more applicants.

 24Medical conditions that FAA deems low risk and has approved for an AME to issue 

under the CACI program include: arthritis, asthma, colitis/irritable bowel syndrome 

(IBS)/Crohn’s, glaucoma, hepatitis c, hypertension, hypothyroidism, migraine and chronic 

headache, pre-diabetes (glucose elevation/intolerance), prostate cancer, renal cancer, 

and testicular cancer, among others.

25Medical conditions that were proposed but not yet approved for CACI, include, for 

example: carotid stenosis, bladder cancer, leukemia, and lymphoma. 

Experts Suggested FAA 

Should Continue Efforts to 

Make the Certification 

Process Data-Driven
Page 15 GAO-14-330 Aviation Safety

FAA authorization for a special issuance that they believe should be 

considered under the CACI program. Their suggestions included, for 

example, non-insulin-treated diabetes, which was a factor in about 17 

percent of the special issuances in 2012; sleep apnea and other sleep 

disorders, which were a factor in about 11 percent of the special 

issuances in 2012;26 and various forms of cancer, which were a factor in 

about 10 percent of special issuances in 2012.27

Although neurological conditions (including migraines, head trauma, 

stroke, and seizures) accounted for approximately 4 percent of special 

issuances in 2012, some experts (5 of 20) thought, as mentioned above, 

that FAA should convene an expert panel to re-evaluate its policies in this 

area. Half of the experts we interviewed also said that FAA could evaluate 

its medical standards based on the relative risk of incapacitation 

associated with various medical conditions, assessed through greater use 

of data. That is, with a better understanding of the likelihood of each 

medical condition to cause a suddenly incapacitating event in flight—

FAA officials have begun 

to allow AMEs to make medical determinations for applicants with certain 

types of cancer under the CACI program and have said that they will 

evaluate other medical conditions to include in the CACI program in the 

future.

 26As of April, 2014, FAA officials told us that they were working to revise the agency’s 

sleep apnea policy and consider how it may be implemented, to ensure that as many 

applicants as possible are issued a medical certificate at the time of their FAA 

examination. FAA currently instructs its AMEs to screen for sleep apnea by asking 

applicants about signs or symptoms and looking for major risk factors of sleep apnea and 

related conditions as part of the medical exam. First-time applicants known to have sleep 

apnea must currently go through the FAA special issuance process, which requires them 

to provide results from a polysomnogram sleep study, among other requirements.

27The percentages in this paragraph describe the portion of the approximately 10.2% of 

applicants who were granted a special issuance by FAA in 2012. If considering the portion 

of all applicants, about 1.8 percent of all applicants had received a special issuance for 

non-insulin treated diabetes; about 1.1 percent of all applicants had received a special 

issuance for sleep apnea and other sleep disorders; and, about 1.0 percent of all

applicants had received a special issuance for various forms of cancer.
Page 16 GAO-14-330 Aviation Safety

based on historic data of accidents and incidents—FAA could modify its 

risk threshold for various medical standards and policies to manage risk.28

As previously mentioned, FAA has begun to collect and analyze data that 

will help it develop a proactive approach to managing aviation medical 

risk; however, FAA officials told us that data from historic accidents and 

incidents can be difficult to obtain and link to medical causes. The officials 

also said that they would need to change how they code, or classify, the 

medical information they collect—and re-code medical information they 

already have—to more accurately classify medical conditions of 

applicants and, therefore, improve the reliability of their predictive model. 

Without more granular data collection on health conditions, officials said it 

is difficult for FAA to accurately determine the level of risk, associated 

with various medical conditions. In addition, officials at FAA and NTSB 

noted that data on medical causes of accidents and incidents are likely to 

be incomplete because not all accidents are investigated in the same way 

and medical causation can be difficult to prove in light of other 

contributing factors. For example, an official from NTSB explained that 

there are different levels of medical investigations performed after 

accidents, depending on factors like whether or not the pilot has survived, 

the condition of the aircraft or severity of the crash, and the number of 

people impacted. As of February 14, 2013, NTSB and FAA agreed to a 

memorandum of understanding (MOU) that will facilitate NTSB’s data 

sharing and record matching for aircraft accidents and incidents with 

CAMI.

 28An example of a risk threshold that has been applied to the medical fitness of pilots, in 

the United Kingdom and elsewhere, is the “one percent rule,” which would result in a pilot 

applicant being denied a medical certificate if their risk of medical incapacitation due to a 

particular medical condition (e.g., heart attack, stroke, seizure, sudden unconsciousness, 

etc.) was determined as being greater than one percent during the year. That is, if there 

were 100 pilots with an identical medical condition, one of them would be predicted to 

become incapacitated at some point during the next 12 months (and 99 would not). 
Page 17 GAO-14-330 Aviation Safety

Although most medical certification determinations are made by one of 

the approximately 3,300 FAA-designated AMEs at the time of an

applicant’s medical exam, approximately 10 percent of applications—or 

nearly 40,000 annually—are deferred to FAA for further medical 

evaluation if the applicant does not meet FAA’s medical standards or has 

a disqualifying medical condition. According to FAA officials, the 10 

percent of applicants who are deferred requires a significant amount of 

resources from FAA’s medical certification division, which in recent years, 

has experienced a backlog of special issuance applications in need of 

review. As of February 2014, an FAA official estimated this backlog at 

about 17,500 applications.

FAA has not met its internal goals for responding to individuals whose 

applications have been deferred. Specifically, FAA has set an internal 

goal of 30 working days to make a medical determination or to respond to 

an applicant with a request for further information. However, according to 

FAA data, the average time it takes FAA officials to make a medical 

determination or request further information from an applicant has 

increased over the past 6 fiscal years, taking an average of approximately 

45 working days—or about 9 weeks—in fiscal year 2013, and more than 

62 working days in December 2013.29

Officials from AOPA stated that some applicants for private pilot medical 

certificates discontinue the application process after an initial denial from 

the FAA because the applicants decide that the cost of extra medical 

evaluations and added time is too great to support what the applicant 

If FAA makes multiple requests for 

further information from an applicant, the special issuance process can 

take several months or longer.

 29This estimate may not account for the full processing time it takes an applicant to 

complete the process, because FAA only measures the time that FAA’s AMCD manually 

codes and enters applicants’ information into its Document Imaging Workflow System 

(DIWS) to when it either makes a determination to issue or deny a medical certificate, or 

requests further information from the applicant. 

FAA Has Identified 

Technical Solutions to 

Improve Its Medical 

Certification Systems, but 

Has Not Set Time Frames 

for Implementation
Page 18 GAO-14-330 Aviation Safety

views as a recreational activity.30

FAA officials at AMCD stated that there are several reasons for the 

increased processing time for applicants requiring special issuances. For 

example, AMCD has faced a technical issue deploying the Document 

Imaging Workflow System (DIWS), a web-based computer system used 

by AMCD to process, prioritize, and track all medical certification 

applications. One AMCD official noted that delays in deployment of the 

system have decreased productivity of the AMCD to as low as just 25 

percent of normal levels. In addition, officials cited multiple backlogs 

throughout the division, such as, the electrocardiogram (ECG) unit, which 

receives up to 400 ECGs each day, and the pathology-coding unit, which 

may require manual coding of medical conditions to feed information into 

DIWS.

However, an official from FAA noted 

that delays can also occur as a result of applicants who may take a long 

time to respond to an FAA request for further evaluation. According to 

AOPA, having information upfront would speed up the process by helping 

applicants understand FAA’s additional medical requirements for a 

special issuance. FAA has increasingly encouraged its Regional Flight 

Surgeons to become more actively involved in making medical 

determinations for applicants seeking a special issuance.

Part of the challenge, identified in FAA’s National Airspace Capital 

Investment Plan, is that the current medical certification systems are 

based on obsolete technology from the 1990s. Accordingly, technical 

working groups at AMCD have identified more than 50 problems and 

potential technological solutions to enhance their systems, including the 

special issuance processes, of which about 20 have been identified as 

high-priority, including improvements to the online application system, 

AMCS, DIWS, and the ECG transmittal and review process. For example, 

officials stated that updating DIWS to import and read electronic files 

would reduce the need to manually scan from paper documents, and 

 30FAA estimated the cost of a medical exam at $88 (in 2006 dollars). We adjusted this 

value, using the consumer price index (CPI), which would be $102.11 (in 2014 dollars). 

FAA also estimated the hourly value of a third-class pilot’s time, based on an hourly wage 

estimate, at $39.13/hour and estimated travel time for the exam at one-and-a-half hours; a 

half-hour to complete the medical application form; and, a one-hour exam. Using these 

estimates and adjusting to 2014 dollars, the total cost to a third-class pilot would be about 

$240 for time and exam expenses. For FAA’s initial estimates, see:Department of 

Transportation, Regulatory Evaluation, Regulatory Flexibility Determination, International 

Trade Impact Assessment, and Unfunded Mandates Assessment (December 2007).
Page 19 GAO-14-330 Aviation Safety

providing AMEs or applicants limited access to DIWS so they can check 

the status of an application could reduce the number of calls AMCD 

receives at its call center.31

In addition to the proposed enhancements, the Office of Aerospace 

Medicine collaborated with the Volpe National Transportation Systems 

Center (Volpe Center), in 2013, to define broader challenges of the 

current medical certification process and develop a strategy to reengineer 

the existing business processes, including the online medical-certification 

system and its supporting information-technology infrastructure. Officials 

from the Office of Aerospace Medicine have said that their effort with the 

Volpe Center will ultimately inform their plan to replace FAA’s current 

medical information systems with the Aerospace Medicine Safety 

Information System (AMSIS), which the agency plans to begin developing 

in fiscal year 2015. FAA officials stated that they envision several longterm positive changes that may result from AMSIS—including redesigning 

the online application system and form, providing applicants with 

information on actions to complete before they meet with their AME, and 

a more transparent special issuance process with the capacity for 

applicants to check the status of their applications. However, FAA officials 

have also identified several challenges to implementing AMSIS, including 

working within the confines of legal and regulatory requirements, 

protecting sensitive information, and obtaining the estimated $50 million 

needed to fund the system.

As of February 2014, FAA officials stated they 

received funding they requested in June 2013, to upgrade the ECG 

system from analog to digital—a process which they estimate will take 

about 11 months to complete. In addition, FAA has not established a 

timeline for implementing its broader set of technology enhancements, 

some of which may be less contingent on resource constraints. A timeline 

to guide the implementation of the highest-priority enhancements would 

help the agency take another step toward reducing the delays and 

bottlenecks in the special issuance process related to FAA’s technology 

issues.

 31AMCD officials estimated that the AMCD receives about 10,000 pieces of mail each 

month, much of which must be scanned and linked to applicant files. FAA currently 

employs approximately 20 FTEs to scan applications and supporting paperwork into 

DIWS, and about 8 FTE call center operators and one supervisor to handle about 10,000 

calls per month. 
Page 20 GAO-14-330 Aviation Safety

One of FAA’s main tools to communicate its medical standards directly to 

applicants, and to solicit medical information from them, is its online 

medical application system. While FAA also offers training and produces 

pamphlets, videos, and other educational material for AMEs and pilots, 

the online medical application system is used by all applicants to apply for 

a medical certificate. (See app. III for FAA’s training programs and other 

communication tools for AMEs and pilots). The system includes 

information such as the online medical-application form and instructions 

used by applicants to submit medical information to their AME and to 

FAA, and a link to the AME Guide, which contains pertinent information 

and guidance regarding regulations, examination procedures, and 

protocols needed to perform the duties and responsibilities of an AME.

We compared the online application system with select guidelines related 

to content, navigation, and design that are considered good practices by 

Usability.gov.32

Providing Additional Useful Information Directly to Applicants: According 

to Usability.gov, a good practice in website design includes providing 

useful and relevant information that is easy to access and use. Some 

experts (7 of 20), including four who were also AMEs, said that applicants 

may be unsure about medical requirements and documentation. 

Based on our evaluation and discussion with experts, we 

identified areas in which FAA might enhance the usability of the online 

application system by (1) providing useful information directly to 

applicants, and (2) using links to improve how applicants navigate 

through the application system.

 32Usability.gov, maintained by the Digital Communications Division of the U.S. Department 

of Health and Human Services, is a resource for federal web designers to make websites 

more usable, useful, and accessible.

FAA Could Enhance 

its Online Application 

System and the 

Clarity of its Medical 

Application Form for 

Private Pilots

FAA Could Enhance 

Usability of its Online 

Medical Application 

System
Page 21 GAO-14-330 Aviation Safety

Representatives of two aviation medical associations also said a lack of 

clarity can lead to delays in processing the medical certification if 

applicants learn during their medical examination that they must obtain 

additional test results or documentation from their primary care physician. 

Some medical experts (4 of 20) said that technological improvements 

would be helpful. For example, FAA could develop a Web page on its 

website or within the online application system with more information for 

applicants. In addition, two pilot associations stated that a specific Web 

page or website for applicants with links to information on various medical 

conditions, their risks to flight safety, and additional medical evaluations 

that might be needed for applicants with those conditions would be 

helpful. The online application system currently contains a link to the AME

Guide; however, applicants may find the 334-page AME Guide—written 

for aviation medical examiners—difficult to navigate and understand and 

therefore, may be unable to find information about specific documentation 

and additional medical evaluations they may need.

FAA officials in the medical certification division said that providing 

documentation requirements to applicants could reduce certification 

delays, AME errors, and the number of phone calls to AMCD’s medical 

certification call center because the applicants would know what 

additional evaluations or documents they should get from their primary 

care physician before they visit their AME for a medical exam. Similarly, 

the FAA officials noted that applicants may not recall information they had 

previously reported in prior medical certificate evaluations or may not 

disclose their complete medical history when they see a new AME. NTSB 

officials stated that the AME cannot see information about any previous 

applications and knows only what the pilot has reported on their current 

application. This means that the applicant has to recall all of his or her 

past medical history each time they apply for a medical certificate.

Additionally, according to the NTSB officials, it would be useful for the 

pilot to access previously reported information and update only what has 

changed since their previous exam. As part of the more than 50 

technological solutions discussed earlier that FAA has identified to 

enhance the special issuance process, the agency has proposed 

providing access to worksheets which specify required medical 

documentation and providing access to previously reported medical data 

to applicants and AMEs. FAA officials stated that these issues, if 

addressed, would facilitate information flow between the applicant, the 

AME and FAA and allow AMCD officials to more efficiently do their work.

Additionally, some experts (9 of 20) said that it would be helpful to 

applicants and treating physicians if FAA posted a list of banned 
 

Page 22 GAO-14-330 Aviation Safety

medications. In a couple experts’ view, without a public list of banned 

medications, applicants may not disclose their medical treatment regimen 

to FAA out of fear of losing or not receiving their certification. NTSB 

recommended in 2000 that DOT develop a list of approved medications 

and/or classes of medications that may be safely used when operating a 

vehicle; however, DOT—including FAA—did not implement the 

recommendation because, in DOT’s view, a list of approved medications 

would be difficult to maintain and would be a liability for the transportation 

industry if the Department approved a medication that later caused an 

accident.33

However, FAA states in its AME guide that maintaining a published list of 

approved medications would not contribute to aviation safety because it 

doesn’t address the underlying medical condition being treated. Instead, 

FAA’s current policy prohibits AMEs from issuing medical certificates to 

applicants using medications that have not been on the market for at least 

one year after approval by the Food and Drug Administration (FDA), and 

FAA has recently updated its AME Guide, to include a “Do Not Issue—Do 

Not Fly” list of several general classes of medication and some specific 

pharmaceuticals and therapeutic medications.

Officials from AOPA told us that the association provides an 

unofficial list of approved and banned medications to its members but 

believes that this information should be made public and provided by 

FAA.

34

 

33NTSB closed recommendation (I-00-2) in 2010, citing unacceptable action by DOT, after 

DOT said that it had no plans to implement it. However, NTSB credited FAA for 

implementing related recommendations on providing information to pilots on the hazards 

of using specific medications when flying (A-00-5) and educating pilots on how they can 

access that information (A-00-6). 

The “Do Not Issue” list 

names medications that are banned—meaning the AME should not issue 

a medical certificate without clearance from FAA—and the “Do Not Fly” 

list names medications that the pilot should not use for a specified period 

of time before or during flight, including sleep aids and some allergy 

medications. FAA officials said that the “Do Not Issue—Do Not Fly” list is 

intended to be a “living document” that they will revisit periodically. NTSB 

officials suggested that it would be helpful if medications that an applicant

discloses on the medical application form could be automatically checked 

against the “Do Not Issue—Do Not Fly” list to notify their AME of the 

applicant’s use of a medication on the list.

34http://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/ph

arm/dni_dnf/. 
Page 23 GAO-14-330 Aviation Safety

Easier Website Navigation: Navigation is the means by which users get 

from page to page on a website to find and access information effectively 

and efficiently. According to Usability.gov, a good practice related to 

navigability is to use a clickable list of contents, thus minimizing scrolling. 

The Pilot’s Bill of Rights Notification and Terms of Service Agreement—

which contains a statement advising the applicant that responses may be 

used as evidence against the applicant, a liability disclaimer, a statement 

of privacy, and a Paperwork Reduction Act statement among other 

statements—requires the user to scroll through what equates to nearly 10 

pages of text (2,441 words over 417 lines of text), viewable through a 

small window that shows approximately 10 to 12 words across and four 

lines down at a time (see fig. 2).35

 35According to guidance provided by Usability.gov, short sentences and paragraphs are 

particularly important to optimize reading comprehension in the online environment.
Page 24 GAO-14-330 Aviation Safety

Figure 2: Screenshot Showing Small Window through which the Reader Must Scroll 

Pages of Information

FAA might enhance the visibility of this information and help applicants 

better understand what they are agreeing to, if it created a larger window 

with hyperlinks to help the reader navigate through various sections of the 

notification and agreement. Similarly, the question and answer page for 

applicants could be enhanced by including clickable links between the 

questions and answers to allow readers to more easily find answers of 

interest to them.
Page 25 GAO-14-330 Aviation Safety

Another good practice, according to Usability.gov, is to design websites 

for popular operating systems and common browsers while also 

accounting for differences. According to a notification on the online 

application system’s log-in screen, applicants are advised to use only 

Internet Explorer to access the system. The system functions 

inconsistently across other browsers such as Google Chrome, Mozilla 

Firefox, and Apple Safari. For example, links to from the medical 

application form to its instructions do not work for Firefox or Google 

Chrome; instead, they lead the applicant back to the log-in page, causing 

any unsaved information to be lost.

As described in the previous section, FAA officials at the medical 

certification division identified technological problems and potential 

solutions to enhance the online application system, but as of April 2014, 

no changes have been made. For example, the officials observed that 

some applicants enter the date in the wrong format, switching the order of 

day and month (DD/MM/YYYY, as opposed to MM/DD/YYYY), which can 

lead to problems when the AME imports the application. As a result, FAA 

officials proposed using drop-down boxes—with the name or abbreviation 

of each month, followed by the day, and the year—to collect date 

information. This proposed solution is consistent with a good practice—

anticipates typical user errors—highlighted by Usability.gov. Additionally, 

the officials noted that it is not uncommon for an applicant to be logged 

out of their session due to inactivity, resulting in a loss of data entered 

during the session. To address this, FAA proposed that the online 

application system incorporate an auto-save feature that would be 

activated prior to the session expiring—consistent with Usability.gov 

guidelines—to warn users that a Web session may be expiring after 

inactivity to prevent users from losing information they entered into the 

online application system.

In addition to these enhancements, FAA collects some information from 

applicants and AMEs regarding their experience with the application 

process. For example, FAA operates a 24-hour call center to answer 

technical questions that applicants, and AMEs may have about the online 

application system throughout the application process. FAA also has 

surveyed AMEs and pilots to collect information about their experience 

with the medical certification process.
 

Page 26 GAO-14-330 Aviation Safety

The Plain Writing Act of 2010 requires federal agencies, including FAA, to 

write specified types of new or substantially revised publications, forms, 

and publicly distributed documents in a “clear, concise, well-organized” 

manner.36 Several years before the Plain Writing Act of 2010—in 2003—

FAA issued Writing Standards37 to improve the clarity of its 

communication. The Writing Standards include guidance for anyone who 

writes or reviews FAA documents intended for internal or external 

distribution. FAA has continued to make efforts in recent years to improve 

its employees’ understanding of plain language and how to incorporate it 

in written documents. FAA’s Plain Language Program in the Office of 

Communications trains employees and supports Plainlanguage.gov, a 

website devoted to improving communication from the Federal 

government to the public.38

Although plain writing is only required for new or substantially changed 

government documents, and is therefore not required for the current 

medical application form, the goal of plain writing is to help readers find 

the information they need, understand what they find, and use it to meet 

their needs. In regard to the medical certification process, this would 

include helping applicants understand each question and more accurately 

complete the application form in the way that FAA intended. In addition, 

stakeholders from two pilot associations were concerned that unclear 

questions on the medical application form could lead to incomplete or 

inaccurate responses, which they said could also lead to applicants’ being 

accused of misrepresenting themselves or falsifying information on the 

application form—an offense punishable by a fine up to $250,000 and 

imprisonment up to 5 years and may also result in a suspension or 

revocation or all pilot and medical certificates.

 

36Pub. L. No. 111-274, 124 Stat. 2861.

37FAA’s Writing Standards include: (1) writing principles—whether the document is 

appropriate for its audience, its content is well organized, and it uses active voice, clear 

pronouns, and short sentences and paragraphs; and, (2) formatting principles—whether 

the document layout and use of headers and font styles, conform with best practices to 

clearly present information to the reader. For more information, see FAA Order 1000.36 

FAA Writing Standards (Mar. 3, 2003).

38On its Plain Language website, http://www.faa.gov/about/initiatives/plain_language/, 

FAA provides links to best practices, standards, and guides. For example, the site 

contains a link to a basic plain language course, documents containing best practices for 

writing letters and writing for the Web, FAA, and federal government standards and 

guidelines, and general information on government plain language initiatives. 

FAA Could Enhance 

Clarity of Its Medical 

Application Form
Page 27 GAO-14-330 Aviation Safety

More specifically, FAA’s Writing Standards also recommend using active 

voice and active verbs to emphasize the doer of the action. Our analysis 

of FAA’s medical application form and instructions showed that in some 

cases, FAA used passive voice although active voice would make the 

statements clearer. According to FAA’s writing standards, because the 

active voice emphasizes the doer of an action, it is usually briefer, clearer, 

and more emphatic than the passive voice. For example, on the medical 

application form the current statement, “Intentional falsification may result 

in federal criminal prosecution,” may be clearer to the applicant if stated, 

“If you intentionally falsify your responses, you may be prosecuted for a 

federal crime,” or a similar, more direct way of notifying the applicant.

However, FAA officials noted that any re-wording of legal warnings or 

disclaimers must be approved by legal counsel. 

We also asked the medical experts to review the online application form. 

In response, many medical experts (12 of 20) we interviewed stated that 

certain questions can be confusing or too broad. For example, some 

experts have said that terms like “frequent,” “abnormal,” or “medication” 

aren’t clearly defined and therefore certain questions could generate 

inaccurate responses. For example, many experts (15 of 20) said that 

question 17a, on medication use, was unclear because, among other 

reasons, the reader may not know whether supplements or herbal 

medicines should be included. Some medical experts (7 of 20) also 

suggested adding items to question 18, about medical history, for areas 

such as cancer and sleep apnea. In 2009, NTSB recommended that FAA 

modify its medical application form to elicit specific information about risk 

factors or any previous diagnosis of obstructive sleep apnea.39

Many of the medical experts we consulted further suggested simplifying 

one question on the form; this question has also been examined by FAA 

(See app. 

IV for a copy of the medical application form.)

 39According to NTSB, obstructive sleep apnea is associated with excessive daytime 

fatigue and leads to an increased risk of accidents and cognitive impairment. NTSB 

recommendations, A-09-61 and A-09-62, direct FAA to do more to identify pilots and 

applicants likely to have sleep apnea. NTSB also suggested that FAA use data it already 

collects, such as an applicant’s height and weight, to screen for risk factors associated 

with obstructive sleep apnea, such as a high body mass index (BMI) value. In response to 

NTSB’s recommendation, FAA agreed with NTSB that obstructive sleep apnea among 

pilots is a significant safety hazard—if unrecognized and untreated—and proposed 

addressing the issue by promoting awareness of sleep apnea in AMEs through the regular 

AME seminar education process, but the agency did not modify its medical application 

form.
Page 28 GAO-14-330 Aviation Safety

officials. Specifically, the question on the form pertains to an applicant’s 

arrests or convictions. For example, many experts (13 of 20) suggested 

simplifying the question. FAA’s writing guidance suggests shortening 

sentence length to present information clearly or using bullets or active 

voice. In addition, FAA officials from the medical certification division used 

a computer program to analyze the readability of the question and 

discovered that an applicant would need more than 20 years of education 

to understand it.

According to FAA officials, the agency can make changes to the medical 

application form for various reasons, including, for example:

• a response to findings or a recommendation made in a report by 

NTSB or by the Department of Transportation Inspector General, or

• a change in medical practices, for example, resulting from 

advancements in medicine.

Since 1990, FAA revised the application form several times, to add or 

remove questions, change time frames related to the questions, or to 

clarify the questions, among other types of changes. When FAA 

announced in the Federal Register that it would replace its paper 

application form with an online application system, the agency said that 

the online application system would allow it to make and implement any 

needed or mandated changes to the application form in a timelier 

manner, resulting in a more dynamic form. However, agency officials 

noted that while they maintain a list of questions on the application form 

that pose problems for applicants, they do not make frequent changes, in 

part, because of the time and resources needed to complete a lengthy 

public comment and Office of Management and Budget (OMB) approval 

processes which, they say, can take up to two years.40

 40Before requiring or requesting information from the public, the Paperwork Reduction Act, 

as amended (44 U.S.C. Chapter 35) requires Federal agencies to, among other things, (1) 

seek public comment on proposed collections and (2) submit proposed collections for 

review and approval by the Office of Management and Budget (OMB). OMB’s Office of 

Information and Regulatory Affairs (OIRA) reviews agency information collection requests 

for approval or disapproval. According to FAA officials and guidance from the OMB, each 

time the medical application form is updated, the FAA publishes a 60-day notice in the 

Federal Register to solicit public comments on the proposed changes, followed by a 30-

day notice in the Federal Register after the FAA has considered the public comments and 

has submitted the changes for OMB’s concurrent review and approval.

FAA officials also 

said that the Office of Aerospace Medicine must balance “plain language” 
Page 29 GAO-14-330 Aviation Safety

with the requirements levied by FAA’s General Counsel to make sure that 

the wording is legally correct and enforceable. While it will take time and 

resources to improve the clarity FAA’s medical application form, if left 

unchanged, the accuracy and completeness of the medical information 

provided by applicants may not be improved.

Aerospace medical experts we interviewed generally agreed that FAA’s 

current medical standards are appropriate and supported FAA’s recent 

effort to authorize its AMEs to certify a greater number of applicants by 

using a data-driven approach to assessing risk through the CACI 

program. Expanding the CACI program, as some experts suggested, 

could reduce the time it takes for applicants with lower risk conditions to 

become medically certified and, more importantly, allow FAA to prioritize 

the use of its constrained resources for medical determinations for 

applicants with the highest-risk medical conditions.

FAA has identified approximately 50 potential technological 

enhancements to its computer systems that support its certification 

process, including adding new functionality to facilitate the process and 

provide applicants with more information about medical requirements. 

According to FAA officials, these enhancements would potentially reduce 

the workload at the medical certification division. Although FAA intends to 

eventually replace its current medical-certification computer systems with 

a new Aerospace Medicine Safety Information System (AMSIS), 

temporary enhancements are expected to help FAA reduce the delays 

and bottlenecks currently posing challenges to the agency. FAA has not 

established a timeline for implementing its broader set of 50 proposed 

technological enhancements, some of which may be less expensive than 

others. A timeline to guide the implementation of the highest-priority 

enhancements would help the agency take another step toward reducing 

the delays and bottlenecks related to FAA’s technology limitations.

The online-application system and form that FAA uses to communicate 

directly to applicants contain confusing questions and instructions that do 

not meet FAA’s own plain language guidance. In addition, broken links 

and other navigability issues make the website difficult to follow. Efforts to 

provide applicants with useful and relevant information and improve the 

clarity of the questions and instructions contained in the online application 

system and form could allow FAA to more clearly communicate medical 

requirements to applicants. These improvements could not only aid an 

applicant’s understanding of the medical standards and requirements, but 

Conclusions
 

Page 30 GAO-14-330 Aviation Safety

also may result in more accurate and complete information provided by 

applicants to better inform FAA’s certification decisions.

To improve the applicants’ understanding of the medical standards and 

the information required to complete FAA’s medical certification process, 

the Secretary of Transportation should direct the Administrator of FAA to

1. develop a timeline for implementing the highest-priority technological 

improvements to the internal-computer systems that support the 

medical-certification process, and

2. enhance the online medical-application system by clarifying 

instructions and questions on the medical application form and 

providing useful information to applicants.

We provided the Department of Transportation with a draft of this report 

for review and comment. DOT provided technical comments, which we 

incorporated into the report as appropriate, and DOT agreed to consider 

the recommendations. 

We are sending copies of this report to the Department of Transportation, 

the appropriate congressional committees, and other interested parties. In 

addition, the report will be available at no charge on the GAO website at 

http://www.gao.gov. 

If you or your staff members have any questions about this report, please 

contact me at (202) 512-2834 or dillinghamg@gao.gov. Contact points for 

our Offices of Congressional Relations and Public Affairs may be found 

on the last page of this report. Contact information and major contributors 

to this report are listed in appendix V.

Gerald L. Dillingham, Ph.D. 

Director, Physical Infrastructure Issues

Recommendations for 

Executive Action

Agency Comments
Appendix I: Objectives, Scope, and 

Methodology

Page 31 GAO-14-330 Aviation Safety

The objectives of this report are to provide information on (1) FAA’s 

medical standards and policies and certification processes, along with 

medical experts’ views on them,1

To meet these objectives, we reviewed pertinent statutes, regulations, 

and FAA documents regarding its pilot medical certification process, 

standards and application form. We also reviewed academic, trade and 

industry articles, government reports, and other relevant literature. We 

interviewed officials from FAA and the National Transportation Safety 

Board (NTSB), and other stakeholders in the pilot medical certification 

process, including officials representing government advocacy, medical 

and legal issues within the Aircraft Owners and Pilots Association (AOPA) 

and the Experimental Aircraft Association (EAA), the Aeromedical Advisor 

to the Air Line Pilots Association (ALPA), attorneys who assist pilots 

through the medical certification process, and representatives from the 

American Diabetes Association.

and (2) steps that could be taken to 

promote private pilot applicants’ understanding of FAA’s medical 

requirements, including potential revisions to the medical application 

form.

2

 1

Private pilots hold third-class medical certifications. Airline transport pilots who serve as 

pilots in command of scheduled air carrier operations must hold first-class medical 

certificates. Pilots who fly for compensation or hire or serve as flight engineers or flight 

navigators generally hold second-class medical certificates. 

In addition, we received written 

responses from the President and representatives from three member 

airlines of the Regional Airline Association, the Executive Director of the 

Aerospace Medical Association (AsMA), and the President and physician 

members of the Civil Aviation Medical Association (CAMA). We also 

visited the Civil Aerospace Medical Institute (CAMI) in Oklahoma City to 

interview representatives of FAA’s Aerospace Medical Certification 

Division (AMCD), and we attended a training seminar for Aviation Medical 

Examiners (AME). To obtain expert opinions on FAA’s medical standards, 

we collaborated with the National Academies’ Institute of Medicine to 

identify aviation medical experts. We provided the Institute of Medicine 

with criteria and considerations for identifying experts, including (1) type 

and depth of experience, including recognition in the aerospace medicine 

professional community and relevance of any published work, (2) 

employment history and professional affiliations, including any potential 

conflicts of interest, and (3) other relevant experts’ recommendations. 

2

We also contacted the American College of Cardiology and the American Academy of 

Neurology to solicit their views but they did not reply for an interview.

Appendix I: Objectives, Scope, and 

Methodology
Appendix I: Objectives, Scope, and 

Methodology

Page 32 GAO-14-330 Aviation Safety

From the list of 24 experts identified by the National Academies, we 

added 3 experts recommended to us and omitted 7 due to their 

unavailability, their concern that they may not have the expertise to 

respond to our questions, or their stated conflicts of interest. We ended 

up with a total of 20 aviation medical experts who represented private, 

public, and academic institutions. Fourteen of the experts are board 

certified by at least one of the American Board of Medical Specialties 

member boards, including 9 who are board certified in aerospace 

medicine. Eight of the 20 medical experts we interviewed are AMEs for 

the FAA, and 16 are pilots or have had pilot experience in the past. Two

experts are from aviation authorities in Australia and New Zealand, and a 

third expert was from the United Kingdom.

Each expert verified that they had no conflicts of interest in participating in 

our study. We conducted semi-structured interviews by telephone with the 

experts in August and September 2013 to solicit their views on FAA’s 

medical standards and qualification policies, the medical application form, 

and FAA’s communication with AMEs and pilot applicants. We also asked 

general questions about aviation medical policies, followed by specific 

questions about private pilots, where applicable. We provided all medical 

experts with relevant background information prior to our interview, and 

we provided the option to bypass questions if they believed they were 

unqualified to respond in a professional capacity. Prior to conducting the 

interviews, we pretested the interview questions with three aviation 

medical experts (two were AMEs and one was also a pilot). We 

conducted pretests to make sure that the questions were clear and 

unbiased and that they did not place an undue burden on respondents. 

We made appropriate revisions to the content and format of the 

questionnaire after the pretests.

Each of the 20 interviews was administered by one analyst and notes 

were taken by another. Those interview summaries were then evaluated 

to identify similar responses among the experts and to develop our 

findings. The analysis was conducted in two steps. In the first step, two 

analysts developed a code book to guide how they will analyze the expert 

responses. In the second step, one analyst coded each transcript of 

expert responses, and then a second analyst verified those codes. Any 

coding discrepancies were resolved by both analysts agreeing on what 

the codes should be. We examined responses to determine if there were 

systematic differences in responses between experts who were and were 

not pilots and between experts who were and were not AMEs. Because 

we found no significant differences between the pilot and AME groups, 
Appendix I: Objectives, Scope, and 

Methodology

Page 33 GAO-14-330 Aviation Safety

we reported the results for the experts as a whole rather than by the pilot 

or AME subgroups.

We used indefinite quantifiers throughout the report—”few” (2-3 experts); 

“some” (4-9 experts); “half” (10); “many” (11-15 experts); and, “most” (16-

19 experts)—to inform the reader of the approximate quantity of medical 

experts that agreed with a particular statement. We only reported on 

issues raised by at least two experts. We interviewed individuals with 

broad aerospace-medicine expertise to provide their expert opinion on 

FAA’s medical standards and qualification policies. While the experts 

provided their opinions on some specific standards, we do not believe 

that these opinions alone provide sufficient evidence to recommend any 

specific changes to FAA medical standards and policies. Rather, the 

information from these interviews provides us with an overall expert 

assessment of FAA’s medical standards, policies, and practices. The 

results of our interviews represent opinions among the experts we 

interviewed but cannot be generalized to the larger population of aviation 

medical experts. See table 2, below, for a list of medical experts we 

interviewed.

Table 2: List of Medical Experts

Name Organization FAA-designated AME

Brent Blue, M.D. Emerg+A+Care

Family Physician,St. John’s Medical Center

FAA Aviation Medical Examiner

Tarah L. Castleberry, DO, MPH. Assistant Professor

Clinical Preventive Medicine

Aerospace Medicine Residency

University of Texas Medical Branch, Galveston, TX 

Senior FAA Aviation Medical Examiner

Mary “Missy” Cummings, Ph.D. Associate Professor of Aeronautics and Astronautics 

Massachusetts Institute of Technology

Peter Demitry, M.D. President, 4D Enterprises

David Gradwell, M.D., Ph.D. Professor, Aerospace Medicine

Kings College

London, UK

Bernard Harris, M.D., M.B.A. CEO and Managing Director of Vesalius Ventures

Richard T. Jennings, M.D. Professor, Preventive Medicine and Community Health

University of Texas Medical Branch, Galveston, TX

Warren Jensen, M.D. Professor, Department of Aviation

Director of Aeromedical Research

University of North Dakota 

Odegard School of Aerospace Sciences

Senior FAA Aviation Medical Examiner
Appendix I: Objectives, Scope, and 

Methodology

Page 34 GAO-14-330 Aviation Safety

Name Organization FAA-designated AME

Kris Lehnhardt, M.D. Assistant Professor

George Washington University School

of Medicine and Health Sciences

Daniel Masys, M.D. Affiliate Professor, Biomedical and Health Informatics

University of Washington

Pooshan Navathe, MBBS, M.D. Principal Medical Officer

Civilian Aviation Safety Authority

Australia

Robert R. Orford, M.D., M.P.H. Assistant Professor of Medicine

Division of Preventive, Occupational, and Aerospace 

Medicine

Mayo Clinic, Arizona

Senior FAA Aviation Medical Examiner

Scott E. Parazynski, M.D. Chief Medical Officer

Director, Center for Polar Medical Operations

University of Texas Medical Branch, Galveston, TX

Russell Rayman, M.D. Former Director,

Aerospace Medical Association

Dennis Sager, M.D. Associate Clinical Professor of Health Care Sciences

George Washington University,

Private Practice

Senior FAA Aviation Medical Examiner

Warren S. Silberman, D.O., MPH Contractor for Aircraft Owners and Pilots Association

Former Program Manager, FAA Aerospace Medical 

Certification

Senior FAA Aviation Medical Examiner

Quay Snyder, M.D., MSPH ALPA Aeromedical Advisor

Jan Stepanek, M.D., M.P.H. Associate Professor of Medicine

Mayo Clinic College of Medicine

Director, Aerospace Medicine Program

Senior FAA Aviation Medical Examiner

Dougal Watson MB, BS, BScMed Principal Medical Officer

New Zealand Civil Aviation Authority

Richard Williams, M.D. Chief Health and Medical Officer

National Aeronautics and Space Administration

Senior FAA Aviation Medical Examiner

Source: GAO, based on information provided by selected medical experts.

In addition to asking medical experts and other stakeholders about their 

view of FAA’s communication of its medical certification requirements, we 

reviewed MedXPress.faa.gov (online application system) used by pilots to 

obtain a medical certificate. We reviewed the Pilots Bill of Rights 

Notification and Terms of Service Agreement, Form 8500-8 (medical 

application form) and instructions, and links within the online application 

system, evaluating that information against federal government websiteusability guidelines and against FAA’s plain language guidelines. We 

evaluated the online application system based on the following criteria (1) 

content—whether the website contained relevant and appropriate 

information users need—and (2) navigation—how easily users can find 
Appendix I: Objectives, Scope, and 

Methodology

Page 35 GAO-14-330 Aviation Safety

and access information on the site and move from one webpage to 

another, focusing on, for example, the clickable links within a website and 

limited reliance on scrolling. In addition, we reviewed various other 

website usability resources and criteria, including Usability.gov, to 

understand the key practices for making websites easy to use and 

helpful. We evaluated the medical application form and its instructions 

based on criteria established by FAA’s Office of Communications, 

including its Plain Language Tool Kit and its Writing Standards. These 

criteria include (1) writing principles—for example, whether the document 

is appropriate for its audience, its content is well organized, and it uses 

active voice, clear pronouns, and short sentences and paragraphs—and, 

(2) formatting principles—for example, whether the document layout and 

use of headers and blank space conform with best practices to clearly 

present information to the reader.

We conducted this performance audit from January 2013 through April 

2014, in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.
Appendix II: Summary of Selected FAA Medical 

Standards

Page 36 GAO-14-330 Aviation Safety

Medical

Certificate

Pilot Type

First-Class

Airline Transport Pilot

Second-Class

Commercial Pilot

Third-Class

Private Pilot

Frequency of medical 

requirement

Every 6 months if 

> 40 years old.

Every year if 

< 40 years old.

Every year, 

regardless of age.

Every 2 years if 

> 40 years old.

Every 5 years if 

< 40 years old.

DISTANT VISION 20/20 or better in each eye separately, with or

without correction.

20/40 or better in each eye 

separately, with or without 

correction.

NEAR VISION 20/40 or better in each eye separately (Snellen equivalent), with or without correction, as measured at 16 

inches. 

INTERMEDIATE VISION 20/40 or better in each eye separately (Snellen equivalent), with or 

without correction at age 50 and over, as measured at 32 inches. 

No requirement. 

COLOR VISION Ability to perceive those colors necessary for safe performance of airman duties.

HEARING Demonstrate hearing of an average conversational voice in a quiet room, using both ears at 6 feet, with 

the back turned to the examiner or pass one of the audiometric tests below. 

AUDIOLOGY Audiometric speech discrimination test: Score at least 70% reception in one ear.

Pure tone audiometric test. Unaided, with thresholds no worse than: 

500 Hz 1,000 Hz 2,000 Hz 3,000 Hz

Better Ear 35 Db 30 dB 30 dB 40 dB

Worst Ear 35 dB 50 dB 50 dB 60 dB

ENT No ear disease or condition manifested by, or that may reasonably be expected to be maintained by, 

vertigo or a disturbance of speech or equilibrium. 

PULSE Not disqualifying per se. Used to determine cardiac system status and responsiveness.

BLOOD PRESSURE No specified values stated in the standards. The current guideline maximum value is 155/95.

ELECTROCARDIOGRAM (ECG)At age 35 and

annually after age 40

Not routinely required. 

MENTAL No diagnosis of psychosis, or bipolar disorder, or severe personality disorders.

SUBSTANCE

DEPENDENCE AND

SUBSTANCE ABUSE

A diagnosis or medical history of “substance dependence” is disqualifying unless there is established 

clinical evidence, satisfactory to the Federal Air Surgeon, of recovery, including sustained total 

abstinence from the substance(s) for not less than the preceding 2 years. A history of “substance abuse” 

within the preceding 2 years is disqualifying. “Substance” includes alcohol and other drugs (i.e., PCP, 

sedatives and hynoptics, anxiolytics, marijuana, cocaine, opioids, amphetamines, hallucinogens, and 

other psychoactive drugs or chemicals). 

DISQUALIFYING

CONDITIONS 

Unless otherwise directed by the FAA, the Examiner must deny or defer if the applicant has a history of 

(1) diabetes mellitus requiring hypoglycemic medication; (2) Angina pectoris; (3) Coronary heart disease 

that has been treated or, if untreated, that has been symptomatic or clinically significant; (4) Myocardial 

infarction; (5) Cardiac valve replacement; (6) Permanent cardiac pacemaker; (7) Heart replacement; (8) 

Psychosis; (9) Bipolar disorder; (10) Personality disorder that is severe enough to have repeatedly 

manifested itself by overt acts; (11) Substance dependence; (12) Substance abuse; (13) Epilepsy; (14) 

Disturbance of consciousness and without satisfactory explanation of cause, and (15) Transient loss of 

control of nervous system function(s) without satisfactory explanation of cause. 

Source: 2014 Guide For Aviation Medical Examiners and 14 C.F.R. § 61.23(d). 

Appendix II: Summary of Selected FAA 

Medical Standards
Appendix III: Selected FAA Training Programs 

for AMEs and Pilots in Aerospace Medicine 

and Communication Tools

Page 37 GAO-14-330 Aviation Safety

AME Training Program/ Communication tool Description

Clinical Aerospace Physiology Review for 

Aviation Medical Examiners (CAPAME) course

Medical Certification Standards and Procedures 

Training (MCSPT)

Prospective AMEs must complete these online courses as a prerequisite to 

becoming an AME. 

Basic AME Seminar Prospective AMEs generally must attend this one-week seminar to be designated 

as an AME.

AME Refresher Seminars

or

Multimedia Aviation Medical Examiner 

Refresher Course (MAMERC)

Practicing AMEs must complete refresher training every three years to maintain 

their designation as an AME. AMEs generally fulfill this requirement by either

attending an AME Refresher Seminar;

or,

completing the online MAMERC course in lieu of attending an AME theme seminar. 

This course can be used as a substitute for a theme seminar on alternate 3-year 

cycles, which extends the time between theme seminar attendance to six years.

AME Proficiency Requirement In addition to the AME training and continued professional refresher courses, AMEs 

generally maintain a proficiency requirement of at least 10 exams per year.

Guide for Aviation Medical Examiners According to the Federal Air Surgeon, FAA policies go into effect when they are 

updated in the Guide for Aviation Medical Examiners, available online. 

Federal Air Surgeon’s Medical Bulletin Published quarterly for aviation medical examiners and others interested in aviation 

safety and aviation medicine. The Bulletin is prepared by the FAA’s Civil Aerospace 

Medical Institute, with policy guidance and support from the Office of Aerospace 

Medicine.

Aerospace Medical Certification Subsystem 

(AMCS)

E-mail notifications are sent to AMEs and their staff through AMCS. AMCS support 

is available by phone, (405) 954-3238, or e-mail, 9-amc-aam-certification@faa.gov.

Pilot Training Program/ Communication tool 

FAA TV and Social Media FAA TV, http://www.faa.gov/tv, is a central repository for FAA videos related to pilot 

medical requirements, among other topics. For example, FAA has produced two 

MedXPress videos: http://www.faa.gov/tv/?mediaId=554 or 

http://www.faa.gov/tv/?mediaId=634

FAA also posts videos on its YouTube page 

http://www.youtube.com/user/FAAnews/videos

FAA also uses Facebook and Twitter to communicate directly with pilots and others 

who choose to follow FAA through social media. 

FAA Safety Briefings Bimonthly publications promote aviation safety by discussing current technical, 

regulatory, and procedural aspects affecting the safe operation and maintenance of 

aircraft. 

FAA’s Medical Certification web page FAA’s medical certification webpage contains information for AMEs and pilots, 

including information about MedXPress, Health and Fitness, and FAA’s Industry 

Drug and Alcohol Testing Program. 

http://www.faa.gov/licenses_certificates/medical_certification/

Appendix III: Selected FAA Training 

Programs for AMEs and Pilots in Aerospace 

Medicine and Communication Tools
Appendix III: Selected FAA Training Programs 

for AMEs and Pilots in Aerospace Medicine 

and Communication Tools 

Page 38 GAO-14-330 Aviation Safety 

Pilot Training Program/ Communication tool 

FAA Pilot Safety Brochures FAA pilot safety brochures provide essential information to pilots regarding potential 

physiological challenges of the aviation environment so pilots may manage the 

challenges to ensure flight safety. Brochure topics include: Alcohol and Flying, 

Medications, Spatial Disorientation, Hearing and Noise, Hypoxia, Pilot Vision, Seat 

Belts and Shoulder Harnesses, Sleep Apnea, Smoke, Sunglasses for Pilots, Deep 

Vein Thrombosis and Travel, and Carbon Monoxide, among other topics. 

MedXPress MedXPress support is available for pilots by phone, (877) 287-6731, or e-mail, 9-

natl-avs-it-servicedesk@faa.gov, 24 hours each day. 

Source: FAA. 
Appendix IV: FAA Form 8500-8

(Medical Application Form)

Page 39 GAO-14-330 Aviation Safety

Appendix IV: FAA Form 8500-8

(Medical Application Form)
Appendix IV: FAA Form 8500-8

(Medical Application Form)

Page 40 GAO-14-330 Aviation Safety
Appendix IV: FAA Form 8500-8

(Medical Application Form)

Page 41 GAO-14-330 Aviation Safety
Appendix V: GAO Contact and Staff 

Acknowledgments

Page 42 GAO-14-330 Aviation Safety

Gerald L. Dillingham, Ph.D., (202) 512-2834, or dillinghamg@gao.gov

In addition to the contact named above, the following individuals also 

made important contributions to this report: Susan Zimmerman, Assistant 

Director; Colin Fallon; Geoffrey Hamilton; John Healey; Linda Kohn; Jill 

Lacey; Maren McAvoy; and Sara Ann Moessbauer.

Appendix V: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(540255)
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